Reading Romanow on Women's Health

Roy Romanow published his Final Report of the Royal Commission on the Future of Health Care, Building on Values: The Future of Health Care in Canada in November 2002. His proposals, which establish the sustainability of Medicare, and promote the continuation of a publicly funded system delivered through non-profit services, were embraced by the many individuals and organizations who have fought hard against the increased push toward a for-profit health system.

However, many women’s organizations, including the National Coordinating Group on Health Care Reform and Women, and the Canadian Women’s Health Network, were disappointed to see that Romanow failed to address the unique health needs of women, who provide the majority of paid health provision, the majority of unpaid health care, and are also the major recipients of health care. The all-important gendered lens was missing from the Romanow report.

In February 2003, the provinces struck a deal with the Federal government in a Health Accord that allots $34.6 billion in federal money over 5 years to the provinces, specifically for health care. Again, those who champion a publicly funded health system were happy to see these desperately needed funds promised to our universal Medicare system, particularly since three important priority areas were listed in the accord: primary care, home care and catastrophic drug coverage.

However, since the Health Accord was largely modeled on the Romanow report, though it was a “Romanow on the cheap,” as news editors referred to it, coming in several billions of dollars under Romanow’s recommendations, it too, failed to take into account women’s specific health needs and concerns. Significantly more money was thrown into the health system, but there was no word of identifying how best to spend this money based on women’s and men’s specific, gendered health requirements.

While Health Canada recognizes gender and sex as two of the 12 determinants of health, neither Romanow nor the current Health Accord takes these determinants into account in any significant way. By failing to provide a gendered analysis, the Romanow Report and the current Health Accord are fundamentally flawed to address long-term health challenges specific to the health needs of both women and men.

Responding To Romanowby The National Coordinating Group on Health Care Reform and Women

Why is health reform a women’s issue?

There are at least six reasons:

1) Care work is women’s work. Women account for over 80% of those providing paid care and a similar proportion of those providing direct personal care as unpaid providers. Reforms over the last decade have meant that there are fewer hours of paid work for providers who have been formally taught the required skills and more hours of unpaid work for those without formal training. The care work in the formal system cannot be understood without recognizing that it is women who do this work and that women’s care is integrally linked to their unpaid caregiving. The Romanow Report fails to acknowledge—much less address—the full range of gendered care work.

While there is much discussion about how people prefer to be cared for at home, there is little about the preferences of those who must provide the care. Six years before the Romanow Commission, Prime Minister Chrétien appointed the National Forum on Health to make recommendations on the future of health care. Women told that group that they did not want to be “conscripted” into care work. But this invisible conscription has only increased, as more people are sent home quicker and sicker and fewer are allowed admission into public institutions or publicly paid home care.

Although this is often described as “sending care back home,” women are taking on tasks and responsibilities their grandmothers never dreamed about. They insert catheters and apply oxygen masks, handle breathing tubes and IVs. Women giving and receiving care are often subject to violence and other risks, especially when the care is provided in isolated households. Without support or training, women providing unpaid care often end up in poor health themselves and may provide poor care. Many women want to care and are rewarded by caregiving. However, inadequate resources and lack of choice limit these rewards while making the caregiving more difficult.

The Romanow Report acknowledges that women do most of the home care and often risk their health in the process. However the failure to consider chronic care and care for those with disabilities leaves out of the Report much of the long-term and stressful women’s work. Equally important, by offering relief in terms of Employment Insurance, the Romanow Report ignores the fact that many women who provide care are not eligible for benefits under this program precisely because their unpaid care work makes it impossible to take on enough paid work.

The application of business practices to health services, combined with cutbacks, have at the same time contributed to deteriorating conditions for those who still have paid jobs. Women employed to provide care are pushed to work harder and faster, with less control over the care they provide. Increasingly, the women who cook, clean, do laundry and serve food are defined as providing hotel services rather than care services, even though the women know they are care workers, and food, environments and hygiene determine health. The Romanow Report defines the work they do as ancillary services, ignoring both the evidence of their critical role in health care and the skills they bring to the work.

The results of the new business strategies are the highest injury rate of any industry, the highest rate of casual employment and low rates of job satisfaction. In other words, their work in health is making women sick. The Romanow Report acknowledges the deteriorating working conditions for those it defines as care providers, but fails to link these deteriorating conditions to for-profit business practices or to the gender of the work force. And it ignores entirely the health of the women who make up the majority of those providing care. Moreover, it offers no concrete recommendations on how to address the work organization problems that are recognized.

2) Women are the majority of those requiring health care services. As the majority of the population and all of those giving birth, it is women who use care more. And women are the overwhelming majority of the elderly who are poor and need care. As well, women account for up to three-quarters of the institutionalized elderly. The failure to consider long-term care either in facilities or at home has particularly negative consequences for women. Moreover, women are more likely than men to have their care needs go unmet. It is also women who take children for care and who take responsibility for children’s health. Yet this dimension of care access is not considered in the Romanow Report, even though healthy child development is recognized by Health Canada as a determinant of health.

3) Women have fewer financial resources than men to assist them in getting or giving care. They are less likely than men to have health coverage through their paid job and more likely than men to be poor. This is particularly the case for women past retirement age, most of whom do not have pensions from their paid work. Thus when public care is not available or fees are charged, women find it more difficult than men to purchase care for themselves, their children or their other dependent relations. It is therefore women who will suffer most from the failure of the Romanow Report to recommend that public funding go only to non-profit services and to prohibit a parallel private system.

4) In spite of the fact that almost all health care is provided by women and women are most of those who receive care, women are a minority of those making policy decisions about health care. They have few means of influencing how major policy decisions are made, even though their daily practices bring so many of them into direct contact with the health care system. The lack of an enforcement mechanism in the Romanow Report leaves women with little influence on the system and few means of ensuring care will be there.

5) The emphasis on evidence in the provision of services may also have a negative impact on women because women are less likely than men to be the subjects in developing evidence. The managerial approach discussed in the Romanow Report, which emphasizes the need for more data as the basis for decision-making, fails to recognize the values set out at the beginning of the Report. Nor does it recognize the gendered ways data are constructed and the ways they tend to ignore diversity. This emphasis on data also fails to take into account the impact of such approaches on those who give and receive care.

6) Cutbacks that increase the reliance on purchased care and reforms that fail to accommodate differences increase inequality among women. First Nations, Inuit and Métis women face persistent and pervasive obstacles in giving and receiving care. Like women from immigrant, refugee and visible minority communities, they often face racism, along with language and cultural barriers. And poor women find it harder not only to stay healthy and care for their children, but also to get the care they need. There is some recognition of these different needs in the Romanow Report, and this is clearly a step in the right direction. However, gender is seen as one of many variables rather than one that intersects with these others to create even greater vulnerabilities in terms of care receiving and caregiving.

Women are facing deteriorating conditions for giving and receiving care, as the Romanow Report documents. However, the full implications of these conditions are often hidden by women’s efforts to make up for the gaps and the negative consequences of system reforms, camouflaging just how far reforms have gone in cutting care. Indeed, women are expected to fill these gaps. They feel responsible and are held responsible for care. Only a gendered analysis can reveal the forces at work in creating these conditions.